In 2016, Kaleida Health, a Buffalo, New York health network with four hospitals and 1 million annual patient visits, faced a serious challenge. Problems were surfacing across its nurse workforce, including high turnover among CNOs at three acute care hospitals for several years running. This came just as Kaleida Health was starting to turn the corner and experience growth after two years of intense changes, including hiring a new leadership team and addressing financial challenges.
Now, there was significant dissatisfaction, distrust, and turnover at the director and nurse manager levels, as well as unrest and low engagement among the nursing staff. Nurses were unhappy with staffing levels and more than 600 had signed cards stating they believed staffing was unsafe. RN staff engagement scores were the lowest of any hospital in the area and well below national averages.
HCAHPS scores were significantly below target and many nursing related scores were below the 20th percentile, particularly in the areas of nurse communication and staff responsiveness. Additionally, all patient experience and safety outcomes domains were below the CMS threshold and several safety outcomes fell below the hospital baseline.
(Cheryl Klass, MBA, BSN, RN, executive vice president and chief nursing executive of Kaleida Health. Photo courtesy of Kaleida Health.)
Senior leadership knew the future success of Kaleida Health depended on leading from the bedside and ensuring high-quality patient care. This meant having a well-trained, high-performing, and engaged nurse workforce. Strong nursing leadership was essential. Most importantly, Kaleida Health needed a nurse leader who could successfully oversee a complete transformation.
Cheryl Klass, MBA, BSN, RN, was this person.
Jody Lomeo, CEO, appointed Klass as executive vice president and chief nursing executive. Not only did her appointment confirm the organization's commitment to lead from the bedside, it also laid the foundation and provided the leadership required for the transformation. It was a big move for Klass, who stepped away from her role as president of Kaleida Health's flagship Buffalo General Medical Center. It required the vision and perspective that the chief nursing executive role could do more for the system as a whole, rather than one hospital.
Klass oversaw a deliberate and methodical change strategy over the course of two years to improve nursing operations, nurse engagement, and care quality. The plan included appointing new nursing leaders across the organization, including CNOs at each Kaleida Health hospital. Klass also appointed a systemwide director of nursing education and professional practice, and a director of women and children's services. In addition, 35 full-time nurse managers and assistant nurse managers came on board, several of whom were promoted from within. Klass also implemented a nurse manager council.
Today, nurse managers across the system meet monthly for information sharing, team building, project work, and continuing education. This was one of the most important aspects of transformation, according to Klass. Other changes included a 10% increase in nursing hours per patient day; 24/7 staffing support; and the appointment of dedicated charge nurses on many nursing units.
As a result, nurse engagement and satisfaction, as well as care quality improved. In 2017, a survey showed overall engagement scores hit a high of 3.90 from 3.77 (on a scale of 1 to 5). The climate of trust jumped from 33% to 59% and RN voluntary turnover improved by 68%. HCAHPS scores improved in several areas between 2015 and the first quarter of 2018, with dramatic improvements in quality of care scores:
▪ 69% improvement in MRSA
▪ 68% improvement in CLABSI
▪ 66% improvement in Colon SSI
▪ 42% improvement in CAUTI
▪ 33% improvement in falls with injury
▪ 27% improvement in C. Difficile
▪ 21% improvement in Sepsis
"These scores clearly point to the success of this nursing transformation," says Karen Kirby, MSN, RN, NEA-BC, FACHE, FAAN, president and CEO of Kirby Bates Associates, LLC, which conducted a nursing assessment on patient care quality and developed a transformation plan for Kaleida Health in 2016. "The difference in the enthusiasm among nursing leaders, particularly the nurse manager group, was dramatic and palpable," she says. "Several of the nurse managers who had been promoted from within had said just one year prior that they would never consider a nursing leadership role at Kaleida Health, despite holding a master's degree. In a year they were transformed and excited to share all the new programs that were being implemented to increase both quality of care and staff engagement."
Rebirth of a Community Pillar After Change From For-profit to Nonprofit Status
After 19 years as a for-profit hospital, Bergen Regional Medical Center of Paramus, New Jersey entered a new era as a nonprofit focused on strengthening quality, employee engagement, and community ties. It was renamed New Bridge Medical Center and is now managed by Care Plus Bergen. New Bridge Medical Center, which has 1,070 beds, serves as a safety-net facility, providing critical access to acute and ambulatory care, as well as niche services such as long-term care, behavioral healthcare, and substance abuse treatment.
In October 2017, Deborah Visconi became New Bridge Medical Center's first president and CEO. Visconi was ready to lead the rebirth of the 102-year-old medical center. She brought with her 25 years of experience in healthcare and a successful run as director of operations at Morristown Medical Center, where she was instrumental in helping improve operating margin by 2%, reduce cost per adjusted patient day by 10%, and save $3 million in supply chain costs.
Visconi had a strong vision for how she would transition New Bridge Medical Center—the largest hospital in the state and the fourth largest public hospital in the United States—into a destination hospital for Bergen County. Visconi and her team started with an ambitious strategic plan to improve clinical operations and employee morale, hire new leaders in key roles, upgrade IT, and create impactful community programs.
Visconi also took three critical steps.
Step 1: Visconi and the leadership team evaluated everything from personnel and clinical operations to infrastructure needs.
Step 2: Visconi held town hall meetings and monthly informal meeting sessions called ‘Dine with Deb' to engage staff and gain a clearer understanding of the culture. An employee appreciation committee was also established to enhance staff recognition and appreciation activities.
Step 3: Leadership introduced a new internal/external communications plan that included developing an employee intranet, offering all staff email accounts (a first in the history of the medical center), and creating a strong social media presence to engage staff, patients, and the broader community.
The medical center, a clinical affiliate of Rutgers Biomedical and Health Sciences, also increased clinical staff to appropriate levels, and Visconi hired senior leaders to oversee Lean management training, IT modernization projects, and quality improvements. Further, New Bridge Medical Center, which has 84 medical detox beds and is the largest provider of the service in Bergen County, began making enhancements to behavioral health and addiction services. Visconi was tireless in her efforts to speak to local and state officials regarding the essential support of opioid programs and education. She also brought NARCAN training programs to the community through New Bridge Medical Center.
Reinforcing vital community relationships has been a crucial part of Visconi's vision for New Bridge Medical Center. The medical center now holds monthly community events, and Visconi and her team frequently attend and support community healthcare activities. The medical center also increased care access for local veterans and is now a participating provider in the Veterans Choice Program. Under Visconi's leadership, New Bridge Medical Center held its first veteran's recruitment fair, hiring a dozen veterans on the spot.
In just six months, Visconi's efforts have reduced the recidivism rate in behavioral health short-term care facility units by 50% and reduced AMA (leaving a voluntary unit against medical advice) rates for addiction services by 16%. Further, 24 new physicians were added from Rutgers Medical School to essential specialty areas in ambulatory care. Lean methodologies deployed in the emergency department improved bed management efficiency, thus eliminating ED diversions. The medical center has also improved care access through new managed care contracts.
While it is still early going, Visconi continues to lay the essential groundwork for New Bridge Medical Center's transformation, says Donnalee Corrieri, MHA, vice president of marketing and public relations. "Ms. Visconi has created a transparent and engaged environment to reenergize her workforce and obtain positive employee and community relations attention, while maintaining a fiscally responsible operation within budgetary parameters. She has infused the 102-year-old facility with new life, passion, forward-thinking staff, and new technology," says Corrieri. "There is now an increased focus on quality with a dedication to transformation and innovation every day."
Houston Methodist Coordinated Care Team: Building a Medicare MSSP Network
In 2017, Houston Methodist healthcare system, which includes one hospital in the Texas Medical Center and six community hospitals, made its first venture into financial risk with a payer in the Medicare Shared Savings Program (MSSP) Track 3, as part of a broader strategy to prepare the organization for value-based care. In one year, the program significantly reduced hospital admissions, readmissions, postacute facility and home health utilization, as well as costs. But getting there involved building an ACO from the ground up.
Houston Methodist Coordinated Care (HMCC) ACO, which is the first MSSP Track 3 program in its market, faced steep goals from the start. Leaders needed to introduce and coordinate value-based care within a seven-hospital system. The team was tasked with developing a primary care network of both employed and independent providers, a nursing care management team with specific patient care programs, and key performance indicators. It also needed to develop a network of collaborations with community partners in order to succeed in value-based care.
The first step was to form Houston Methodist Coordinated Care. Developing a robust data and analytics strategy was central to HMCC. To that end, HMCC's leadership team tapped into claims data that provided key insights into quality, cost, and utilization goals. The population health advisors team also shared quality and utilization data with PCPs and specialists. At the same time, the nursing care management team used predictive analytics to enroll and engage patients in several population health programs.
HMCC also improved patient access and care coordination in key areas, including primary care, urgent care, the ED, postacute care, and home healthcare. Primary care physicians focused on ACO quality metrics and documentation to reflect the complexity of care provided to each patient, as well as making sure patient referrals and hand-offs were tracked. The postacute team engaged more than 19 skilled nursing facilities in the greater Houston area and implemented a home health review strategy with PCPs.
The case management team worked closely with physicians, patients, and home health agencies to make more accurate recommendations, thus reducing home health utilization and providing patients with the services needed. Moreover, the organization's social work/case management team developed a value-based discharge planning model for MSSP patients that takes into consideration the social determinants of health, including both nonclinical and clinical factors, when discharging patients.
As a result of these developments, primary care physician post-discharge follow-up appointments, fall risk screenings, and depression screenings increased. The organization has also bumped up urgent care utilization after hours and on weekends to keep patients out of the ED when appropriate. A high priority patient access line, Call your Nurse, establishes continuity between nurse teams and patients.
Ensuring physicians had connectivity to ACO quality goals was also essential. The team worked with private practice physicians to achieve a level of IT interconnectivity with seven different EHRs. Today, not only are physicians able to access patient medical records, but dashboards enable the team to monitor quality efforts and metrics in real time. The team's focus on quality at the patient, physician, and practice level is directed by real-time data and the review of outcomes.
In the first year, HMCC decreased the following:
Hospital admissions – 6%
Hospital readmissions – 0.5%
Inpatient rehab facility utilization – 14%
Long-term acute-care utilization –16%
Skilled nursing facility utilization – 9%
With this success, the ACO is growing its primary care network. The number of primary care physicians has increased from 128 to 164, and Medicare beneficiaries have climbed from 16,299 to 22,500 in the second year.
"Our first year was a real journey for our health system and our ACO team," says Julia Andrieni, MD, FACP, vice president population health and primary care, and president and CEO of HMCC. "Our HMCC team is known for their dedication and data-driven approach to innovation. HMCC took risk in an MSSP Track 3 program, which drove transformative change on a system level."
Clinical Transformation Despite Hurricane and Fire
In 2016, the University of Texas Medical Branch (UTMB), which includes four hospitals and is a member of Texas Medical Center, ranked a dismal 76th out of 102 other academic medical centers in a quality and accountability ranking study. The study looked at mortality, efficiency, safety, effectiveness, patient-centeredness, and equity measures. Gulshan Sharma, MD, chief medical and clinical innovation officer, knew that Galveston, Texas–based UTMB could do better and helped lead a successful transformation in the face of multiple challenges.
In 2017, Sharma and UTMB's senior leadership team launched an initiative to accelerate five years of earlier work aimed at improving UTMB's performance from mediocre to outstanding. The goal: Move from a 3-star performer in the Vizient Quality and Accountability Study to a top 20 academic health center in the United States. Through a concerted effort across the entire organization, this goal was realized, despite the fact that during that year UTMB endured a major hospital fire and a hurricane.
The fire, which occurred in January 2017 at UTMB's John Sealy Hospital in Galveston, caused the evacuation of 110 patients, their visitors, and the staff caring for them. Many areas of the hospital suffered smoke damage. As a result, major service areas, such as the cardiac catheterization/electrophysiology lab, women's and infants' services (which performs 6,000 deliveries a year), an adult burn unit, and other services were unable to return to the hospital for several months.
In August 2017, the hospital was also impacted by the catastrophic Hurricane Harvey. During the hurricane, UTMB accepted patients who were evacuated from surrounding areas. Impasses created by the storm, however, led to serious challenges in obtaining critical supplies, such as lifesaving blood products. Meanwhile, a number of clinical staff lost their own homes and possessions.
Nevertheless, UTMB continued its clinical transformation and learned at the end of 2017 it had exceeded its goal in the new Vizient Quality and Accountability Study. UTMB moved from 76th to 9th place among 107 peer academic medical centers. In addition, the organization met its budget for the fiscal year. As efforts continued in 2018, UTMB continued on a positive trajectory in the same study. Today, UTMB ranks 4th in the nation among 99 comprehensive academic medical centers.
UTMB also experienced other significant achievements, including improving patient experience and mortality goals. In the HCAHPS patient satisfaction survey category of "Rate the hospital a 9/10," UTMB climbed from the 59th percentile (with 73.7% of patients ranking the hospital 9/10 at the end of calendar year 2015) to the 90th percentile (with 82.8% of patients ranking the hospital a 9/10 at the end of calendar year 2017). UTMB also improved in the mortality domain of the Vizient Quality and Accountability Study. UTMB moved from 94th place in 2016 to 55th in 2017—and finally to an impressive 5th place in the 2018 study.
Dr. Sharma played a key role in these successes, working closely with UTMB's CEO, executive vice president, and the system chief nursing and patient care services executive, among other members of the health system executive leadership team, to ensure that the system and medical staff were closely aligned to achieve quality and patient experience goals. "Dr. Sharma spearheaded initiatives aimed at improving mortality and safety, which accounted for 50% of the Vizient Quality and Accountability Study. A considerable amount of work went into reducing potentially preventable 30-day readmissions and length of stay," says David Marshall, system chief nursing and patient care services officer.
Healthcare executives that are transforming healthcare financially, clinically and operationally
Winner:University of Texas Medical Branch – Gulshan Sharma, MD, chief medical and clinical innovation officer
In 2016, the University of Texas Medical Branch (UTMB), which includes four hospitals and is a member of Texas Medical Center, ranked a dismal 76th out of 102 other academic medical centers in a quality and accountability ranking study. The study looked at mortality, efficiency, safety, effectiveness, patient-centeredness, and equity measures. Gulshan Sharma, MD, chief medical and clinical innovation officer, knew that Galveston, Texas–based UTMB could do better and helped lead a successful transformation in the face of multiple challenges. Read the complete profile ...
Winner:Houston Methodist Coordinated Care - Julia Andrieni, MD, FACP, vice president population health and primary care, and president and CEO of HMCC
"Our first year was a real journey for our health system and our ACO team," says Julia Andrieni, MD, FACP, vice president population health and primary care, and president and CEO of HMCC. "Our HMCC team is known for their dedication and data-driven approach to innovation. HMCC took risk in an MSSP Track 3 program, which drove transformative change on a system level." Read the complete profile ...
Winner: New Bridge Medical Center – Deborah Visconi, president and CEO
In October 2017, Deborah Visconi became New Bridge Medical Center's first president and CEO. Visconi was ready to lead the rebirth of the 102-year-old medical center. She brought with her 25 years of experience in healthcare and a successful run as director of operations at Morristown Medical Center, where she was instrumental in helping improve operating margin by 2%, reduce cost per adjusted patient day by 10%, and save $3 million in supply chain costs. Read the complete profile ...
Winner: Kaleida Health – Cheryl Klass, MBA, BSN, RN, executive vice president and chief nursing executive
Senior leadership knew the future success of Kaleida Health depended on leading from the bedside and ensuring high-quality patient care. This meant having a well-trained, high-performing, and engaged nurse workforce. Strong nursing leadership was essential. Most importantly, Kaleida Health needed a nurse leader who could successfully oversee a complete transformation. Cheryl Klass, MBA, BSN, RN, was this person. Read the complete profile ...
Health systems are tasked with managing increasingly complex and tightly regulated clinical programs and payer pressures, as well as strategizing new ways to compete for patients and organ donors.
This article first appeared in the June 2016 issue of HealthLeaders magazine.
Just a few decades ago, organ transplantation was still a relatively new frontier in medicine. In recent years, however, much has changed. Clinical advances, greater numbers of organ donors, changing reimbursement structures, sophisticated administrative models, and ever-tightening government regulations have led to improved healthcare outcomes, more individuals receiving transplants, and the introduction of new transplant procedures.
In 2015, there were 30,973 organ transplants in the United States, surpassing the 30,000 mark annually for the first time, according to the Organ Procurement and Transplantation Network. What's more, there has been an increase in donors "upon cardiovascular death as opposed to brain death," and African American and Hispanic deceased donors increased over the last year, according to the OPTN.
"I've seen the field of transplantation evolve from one that was absolutely new and, as a result, almost entirely unregulated, to a field that is arguably the most regulated in the field of healthcare," says Steven Colquhoun, MD, FACS, director of the Abdominal Multi-organ Transplant Center at the Keck School of Medicine at the University of Southern California in Los Angeles.
Increasing oversight from the United Network for Organ Sharing, the Centers for Medicare & Medicaid Services, and The Joint Commission, which provide outcomes information for each transplant program in the United States, not only ensures the quality of transplant programs but is leading to greater innovation, better organ donor matches, and a lessening of racial and other disparities when it comes to determining who receives an organ.
In December 2014, UNOS changed kidney allocations rules, factoring in considerations other than a person's place on the wait list. Among other changes, the new system is priority matching patients and donor kidneys with the highest life expectancies and "increasing priority for candidates whose immune system is not compatible with most donor kidneys," according to the OPTN.
For Colquhoun and other transplant leaders, as the world of transplantation evolves, they are tasked with managing increasingly complex and tightly regulated clinical programs and payer pressures, as well as strategizing new ways to compete for patients and organ donors.
Success key No. 1: Create a high-performing matrix
At the Bronx, New York–based Montefiore Einstein Center for Transplantation, which performs liver, kidney, and pancreas transplants, Milan Kinkhabwala, MD, chief of the division of transplantation at the center and director of abdominal transplantation, stresses that successful programs must have administrative structures that can accommodate the potential for strong revenue, while at the same time handling regulatory oversight and risk.
Transplant administrative structures have changed a lot over 20 years, he says. "It used to be driven by surgeons who were part of surgical departments. They performed the surgery, administered all of the things in the program." There was no standardization, minimal regulatory oversight, and payment was largely fee-for-service.
Now, "most hospital systems that are doing transplants on a large scale have organized their transplant programs into some kind of matrix center," says Kinkhabwala, who oversees 100 employees. By matrix he means a tightly coordinated center with a physician and an administrative leader who work together tending to everything from business planning and regulations to quality and outreach.
"Transplant physician leaders need to be matrix leaders, interacting with a lot of different departments and division leaders," says Kinkhabwala. "They have to be bridge builders to some degree and develop agreements and relationships with everybody from radiologists and other surgeons to operating room personnel. I'm a busy transplant surgeon, but I spend 80% of my time in program administration."
Montefiore has designated transplantation as one of five centers of excellence within the health system. The transplant center has dedicated administrative leadership from the hospital, and separate budgets, marketing resources, and quality oversight. Since Kinkhabwala joined Montefiore eight years ago, kidney transplants have gone from a low of 109 in 2011 to 168 in 2015. "We had a very successful year in kidney transplants. It was a record year," he says.
"When I came to Montefiore, we set out to organize the center of excellence and build on an existing kidney program," says Kinkhabwala. "I knew what I needed in terms of floor capacity, nursing, clinical protocols, and faculty development, but I needed a hospital partner to help me execute that vision." He stresses that the physician leader's vision must be in sync with hospital goals.
Kinkhabwala says the transplant center must operate like a well-oiled machine because of the type of patients it sees. "If there's a problem in one part of the assembly line, the whole thing kind of falls apart. If your flow of patients, for example, is dependent on a financial counselor getting insurance clearance for patients and you have a financial counselor that's not working out well, or you don't have enough of them, then your whole assembly line could stop because of one person, and that could affect hundreds of people."
Success key No. 2: Redefine each patient's experience
USC's Abdominal Multi-organ Transplant Center performed 125 liver transplants and 152 kidney transplants in 2015 as well as six pancreas-only transplants in 2015, according to OPTN. Transplant surgeon Colquhoun, who specializes in liver transplantation and hepatobiliary surgery, has been on the job there for less than a year, but already his top goal will be to take patient experience to a new level in the transplantation world.
"While we don't really have an issue with our outcomes and things are generally running pretty smoothly, I think one of the themes in healthcare, in general, is always continuously circling back and trying to make things better."
For Colquhoun—who founded a new liver transplant program at the University of California, Davis, and served as the director of Los Angeles–based Cedars-Sinai Medical Center's liver transplant program for 20 years—patient experience goes beyond convenience, since patients receiving a transplant are critically ill. "Making things go faster and efficiently, optimizing ongoing communication, and managing patient and family expectations is critical, since anyone needing a transplant is by definition facing a more or less life-threatening disease condition," he says. "All of these factors are of paramount and often urgent in importance."
One area Colquhoun is zeroing in on is streamlining the exhaustive testing process patients must endure prior to surgery. "As one might imagine, the process for evaluating an individual's candidacy for a transplant is extremely complex and requires not only an exceptional number of tests and studies, but also input from a surprising number of healthcare specialists," he says. "For the sickest patients, these tests and encounters happen in the hospital with some efficiency. However, for the 80% or so of patients who are not hospitalized, the sheer volume of tests and visits can be onerous," he says.
The logistics of coordinating all of this typically takes weeks for most large programs, given that patients who are sick with life-threatening diseases, are not feeling well, have to take days off of work and may have to travel great distances and rely on family members for transportation, says Colquhoun.
Colquhoun and his team want to reduce this process to a single day. It may sound like an insurmountable challenge, given that patients require everything from lab tests to MRIs as well as input from a dozen or more specialists and clinicians, but Colquhoun says he has done it before at other organizations and insists it can be done at USC. The plan will involve tight coordination with other clinicians and labs.
For example, he says, it may mean that the echocardio lab clears its schedule one day a week to accommodate several patients. "A lot of times just talking with all the various parties, getting things mapped out in advance and planned is what's required," he says. Also, Colquhoun says the organization will be starting an ambassador program, in which previous patients will interact with new candidates and their families, and physically guide them to tests and visits.
Success key No. 3: Be a strategic list manager
List management innovation is essential to maintaining high-quality rankings. "If you think about the transplant as a business, what we're really involved in is the business of list management," says Montefiore's Kinkhabwala.
"We're in the business of getting people with organ failure and evaluating them to be put on a waiting list, and then maintaining their health on the waiting list until they get in a surgical operation, and then provide their aftercare." Because donors are allocated based on an organization's wait list, it's important to always be working on maximizing your list number, stresses Kinkhabwala. But, it's not merely as simple as having a larger wait list than other transplant centers. List management strategy involves a deep understanding of how organ allocation works.
In the not so distant past, some organizations would list every patient who came through the door regardless of of how sick they were or how long they would have to wait for a transplant, explains Kinkhabwala. The downside to this strategy, he notes, is that your list size balloons up, resulting in low transplant rates.
Also, kidney allocation has changed recently, he says. "In the past, your clock started ticking when you were referred to the transplant center and they put you on the list. Now, your clock starts from when you started on dialysis." A better list-management strategy for kidney is to evaluate the patients, manage the condition, and defer listing them until they are closer to requiring transplantation. "That makes the list size smaller, your transplant rate higher, and your costs go down because you're not spending as much on testing people who are not going to be transplanted right away." The same strategy can be applied to liver transplants, adds Kinkhabwala.
Success key No. 4: Have an innovative donor strategy
Despite the advances in transplantation, the reality is more than 77,000 people are active waiting list candidates for an organ transplant, according to UNOS. One way to reduce this list is by expanding organ procurement methods, including expanding living donor programs.
Tim Taber, MD, a transplant nephrologist and medical director of kidney and pancreas transplantation for Indiana University Health and the chief medical officer for Indiana Donor Network, says IU Health Transplant has deployed several strategies to bring in more donors. To start, he says, it is critical to be willing to travel.
"We have built a reputation for having physicians who are willing to travel to hospitals across the country at any time of the day or night to take a closer look at donor organs to see if they could be suitable for a transplant back in Indiana," says Taber. "Doing so gives our doctors access to more organs to consider for patients."
IU Health Transplant performed 145 liver transplants, 177 kidney transplants, and 26 pancreas transplants in 2015, according to the OPTN. Taber, who works with a team of nearly 100 clinicians and specialists, says that it is important to examine every organ. "IU transplant surgeons review each organ individually, which means we are able to use more organs and significantly reduce wait times."
His top goal this year is to expand the kidney living donor program at IU Health Transplant. He says about one-third of all kidney donors at IU Health Transplant are living. To increase this percentage, he says, IU Health Transplant has also been doing paired donations for several years. The paired donation process works to procure a living donor for individuals who have a living donor who isn't a match.
IU has also started a donor champion program that helps potential recipients find a donor and teaches them how to talk to people about donations. "The other thing we're doing is trying to do a better job using kidneys that are on the margin of what we've used before and trying to push the boundaries of the quality of kidneys we've taken in the past," says Taber. "Nationally, we just haven't done a good enough job of that. A lot of kidneys are turned away that are procured that probably could be used in the appropriate circumstances."
Montefiore's Kinkhabwala is looking to make improvements to the transplant program by growing its number of living donors. "We want a higher ratio of living donors, because recipients of live donors generally have better outcomes," he says. "We can transplant them quickly and the outcomes are more reliable."
Kinkhabwala says national benchmarks show that about 50% of kidney donations nationally are living donors. "At our program, it's only about 20%, so we have a long way to go to get to at least the national average for living donation, and part of that is our demographic." One way Montefiore is addressing this issue is by going outside of its service area to other parts of the state to attract patients who may have more living donors, he says.
Success key No. 5: Focus on long-term, coordinated care
Montefiore performed 39 liver transplants in 2015 and 46 the year before, according to OPTN data. Kinkhabwala notes that liver transplant volumes need to be between 50 and 70 to maintain a high-quality ranking. Growing the program is a challenge given the competition in New York for transplant services as well as clinical advancements.
"In the downstate area, there are four or five doing liver transplants, so there are a lot of hospitals that are competing for the same patients," says Kinkhabwala. He adds that better treatments for hepatitis C also make it less likely that liver transplantation will be a growth area down the road.
Still, the plan is to grow the program by taking a more expansive approach to the service line, explains Kinkhabwala. "It's more accurate to call it an organ failure service line." With that approach in mind, Montefiore is developing a model of care similar to an ACO for its liver programs, treating all liver conditions, regardless of transplant need, including hepatitis and liver cancer.
"We want to provide all of the services in the health system that eventually, like a pyramid, may lead to transplant." This broader approach also helps other service lines, such as oncology. Regardless of disease stage, "we're taking care of them holistically for life, and we'll actively manage everything in their care, whether that's a psychiatric problem, or if someone with cirrhosis is an alcoholic, then it's our job to get them intervention for alcohol dependency. That is very unique in healthcare," says Kinkhabwala.
Still, despite these efforts, he says there is pressure on revenue in heavy managed care regions because larger insurers demand transplant centers to become centers of excellence. "Those centers of excellence are really vehicles to negotiate lower rates," Kinkhabwala adds. Ultimately, he says, "there's a tremendous halo effect, and there's an elevation of the case mix index for the hospital as a result of the transplant program, which is important for overall reimbursement."
It is not enough for an organization to say it is geriatric-friendly. Geriatric EDs need to monitor hospital admission rates, readmission rates, patient transfers, patient outcomes, and patient experience to help prevent avoidable hospitalizations.
This article first appeared in the May 2016 issue of HealthLeaders magazine.
Hospital emergency departments have been challenged by a variety of factors, including the impact of healthcare reform, increasing numbers of people living with multiple chronic conditions, and a rapidly growing aging population.
One solution is the geriatric ED, which offers emergency care tailored to the specific needs of older adults, along with an opportunity to improve healthcare outcomes and reduce unnecessary hospitalizations and readmissions. In 2007, there were approximately 45 GEDs in the United States. "Today we believe there are over 100, and momentum is underway. It is very promising," says Terry Fulmer, PhD, RN, FAAN, president of the John A. Hartford Foundation in New York City, which supports initiatives to improve healthcare for older adults and seeks to grow the field of geriatric emergency medicine. Roughly 40 million Americans are 65, says Fulmer. What's more, she adds, is that people 85 and older are now the fastest growing population. As the population of older adults grows, emergency medicine experts believe GEDs could double in number.
GEDs are evolving and vary widely, from those with dedicated beds in a traditional ED to those with separate units that treat only older patients. Because GEDs are a relatively new care model, healthcare organizations may face various challenges when it comes to design, operations, staffing, and training. Successful GEDs implement clinical protocols and GED guidelines supported by multiple clinical associations that are aimed at helping providers quickly and efficiently assess, triage, and treat older patients. With the emergency room sitting at the intersection of outpatient and inpatient care, GEDs have the potential to significantly improve care for older patients.
"There's an opportunity now for the ED to be a partner in terms of care coordination and safely preventing avoidable hospitalizations," says Ula Hwang, MD, MPH, FACEP, an emergency physician, researcher, and an associate professor at the Icahn School of Medicine at Mount Sinai, who helps guide clinical GED operations at the 1,171-bed Mount Sinai Hospital in New York City. Not only that, but as GEDs evolve, they have the potential to change how care is delivered across the emergency department and throughout the entire hospital.
Success key No. 1: Design the right physical setting
Older adults have unique medical needs that typically are unmet by standard emergency departments. Aside from the complaints that prompt them to the ED, older adults often have underlying medical conditions, including frailty; sensitivities to light, heat, and sound; as well as delirium and, with growing frequency, dementia. Having the right physical environment in the GED—including special furniture, equipment, and visual elements—is important, says Fulmer. For example, when it comes to acoustics, older people often have hearing impairments. "You have to think about how you will talk to older individuals who might have hearing impairments while not shouting at others who do not have an impairment," she says.
"We opened up a separate physical space that catered more to and was better for older patients," says Denise Nassisi, MD, FACEP, director of the geriatric ED at Mount Sinai Hospital. The GED was launched in February 2012 to meet the needs of its patients age 65 and older, who otherwise would go to the hospital's busy main ED, which sees more than 100,000 visits per year. The GED has 14 treatment spaces, nonskid and nonglare floors, handrails, and high-back chairs that are easy to get in and out of. Mount Sinai's GED features also include reading glasses, hearing devices, and pressure-reducing mattresses. "It's just a quieter, more comfortable space… making it easier for patients to hear and to see, and less likely to become confused and delirious," says Nassisi, who is also associate professor in the departments of medicine and emergency medicine at the Icahn School of Medicine at Mount Sinai in New York City.
Success key No. 2: Build an interdisciplinary team
Geriatric emergency medicine is a team sport. "You start with the conviction that the best care will be delivered by interdisciplinary teams of people who have special credentialing," says Fulmer. She adds that geriatric EDs must have three key characteristics: special knowledge, special protocols, and special staff with expertise. It is this foundation that enables providers to recognize symptoms that are typical of and unique to geriatric patients. "Older adults may present with the same conditions as younger patients, but they also may have distinctly different symptoms," says Fulmer.
For example, a younger individual having a heart attack might present with chest pain, while an older person might come in with confusion or jaw pain," says Fulmer. "When an older person presents to the emergency room with a change in mental status, or they appear confused, that can be the harbinger of any number of acute problems. The presentation can be pretty unique in older people and needs to be managed appropriately by knowledgeable people."
Lining up a strong interdisciplinary team before day 1, is critical, Nassisi says. A lot of planning took place before Mount Sinai's GED opened. "We formed a very broad interdisciplinary team to address some of the complex issues that elderly patients who come to the emergency department face," says Nassisi, noting that it was important to "make a cultural change in emergency medicine." For example, she says, in the traditional ED culture, a frail elderly patient who takes a lot of medications and has multiple comorbidities, as well as a gait disturbance, will be treated with an abundance of caution. "The culture in the past was, 'There's a lot going on. I want to make sure they're OK. I had better just admit them,' " says Nassisi.
Today, however, the interdisciplinary team, which is trained to work with older adults, is establishing new processes and advanced care coordination. "We partner with a medical team, including nurses, social workers, physical therapists, our geriatric medicine colleagues, and pharmacists to look at the evidence first," says Nassisi, stressing that hospitalization may not be in an older person's best interest. "Older patients who get admitted often do worse. They tend to get delirium, have iatrogenic complications, and they also undergo a functional decline that they may not recover from," says Nassisi.
The interdisciplinary model may involve bringing a social worker to the ED to meet with the patient and assess the need for home health services. Or a physical therapist may evaluate that a patient's gait is safe, says Nassisi. "We also have our pharmacist meet with and work with patients to get an accurate medication list and identify any medications that might not be appropriate for them to be on." GED experts stress that it is important to be able to offer these services 24 hours a day to avoid having to admit patients to the hospital.
Nassisi also notes that providing access to transitional care nurses in the GED has been a game-changer in terms of helping patients navigate the healthcare system. "They do on-site assessments of the patient, are able to screen for delirium, cognitive dysfunction, and depression, and are able to assess what their needs are in the home," she says. They also do outpatient referrals and coordinate with homecare services to make sure the patient has the appropriate follow-up. "Usually, we have a call in 24 to 48 hours to see how the patient is doing at home and then further follow-up calls," says Nassisi. "They're at regular intervals just to make sure that everything has transitioned successfully in the outpatient setting. The patients are getting good-quality care and are happy."
Success key No. 3: Hone screening, triage processes
Older patients are at risk for geriatric syndromes, including delirium and dementia.
Successful geriatric EDs have finely honed systems that allow them to accurately assess, screen, and triage older patients early on during the visit. Triaging can be a lengthy process in the traditional ED because case management usually happens late in the visit, and generally after the physician has assessed the patient. This may mean an older patient has to wait hours for staff and outside agencies to coordinate services and medications before going home or transitioning to a new care environment.
This and other care practices for the elderly didn't sit well for an innovative emergency physician at the University of North Carolina. And so a decade ago Kevin Biese, MD, a geriatric emergency physician and associate professor and vice chair for academic affairs of the department of emergency medicine at UNC's Chapel Hill School of Medicine, started implementing new education and care processes for older patients.
Today, along with many other care practices, Biese and his team are piloting a patient vulnerability assessment that includes a questionnaire with 16 questions that is filled out by patients or family members of all patients over the age of 65 who present at UNC's two emergency departments, which have been offering geriatric emergency services over the past year.
"That information is given to case management up front to help them identify who to see so that they can be doing their evaluation at the same time that I'm doing my evaluation," says Biese. "Then we can decide together, based on available resources, the best outcome for that patient," he adds. "We have had some good success with it, and it is helping case managers get the information that they need in our ED to identify who they should be seeing earlier on."
Biese says the geriatric emergency services program is making steady progress at UNC. "We don't have a separate geriatric ED at UNC, nor do I necessarily think we should. Through education and care processes, and now starting on structure, we are in the process of making the entire ED geriatric appropriate." Both EDs, UNC Main Campus and UNC Hillsborough Campus, will continue to explore opportunities to expand geriatric emergency services.
Success key No. 4: Provide geriatric training for all
Because elderly patients can often have unique symptoms and conditions, geriatric ED programs must be vigilant about keeping up with training and education. "We offer education for everyone, including registration associates, nursing staff, ER techs, physician assistants, residents, and providers," says Nassisi. "There is a core team, but also it is making sure that everyone who works in the department is aware of patient issues and is trained," says Nassisi.
Mount Sinai also has dedicated pharmacists in the emergency department who went through geriatric certification, notes Hwang, an early proponent of geriatric emergency care. "This is something that puts some teeth behind the belief in what's happening as opposed to just saying, 'Well, that's great, go do it,' but then you don't actually provide them any support."
"We have robust educational processes for our physicians and nurse champions, as well as enhanced case management support for our physicians and innovative protocols for integrating their input into the care of older adults."
She also notes that Mount Sinai Hospital, along with two other hospitals, participates in the Geriatric Emergency Department Innovations in Care through Workforce, Informatics and Structural Enhancements, a Centers for Medicare & Medicaid Services clinical demonstration program. GEDI WISE is a three-year program designed to provide clinical, workforce, and informatics support to geriatric emergency care.
When Biese finished his emergency medicine training in 2006, he and his colleagues had little exposure to geriatrics. "I became concerned about the way older adults were treated in our emergency departments by very caring nurses, physicians, and the whole team, who all wanted to do the best thing. Without the training, without systems to support best practices, without even knowing what best practices are, it was obvious that older adults were getting hurt," he says.
"There needs to be a physician education program to really help train the ER docs in some geriatric principles of care," Biese says. "We have robust educational processes for our physicians and nurse champions, as well as enhanced case management support for our physicians and innovative protocols for integrating their input into the care of older adults." Additionally, Biese helped start a geriatric emergency medicine fellowship at UNC, which graduated its first fellow in 2014. He has also helped write guidelines for national fellowship programs. As a result, he says there are five national geriatric emergency fellowships.
Success key No. 5: Be vigilant about metrics
It is not enough to say you are geriatric-friendly. Geriatric EDs care can vary widely from very specific approaches to really just cosmetics, notes Fulmer. Organizations need to be monitoring hospital admission rates for older adults, readmission rates, patient transfers, patient outcomes, and patient experience.
Patient outcome areas include how well they avoided adverse drug events and reduced hospital lengths of stay, says Hwang, noting that it is also important to look at the ED length of stay. While it is too early to share results from Mount Sinai's participation in GEDI WISE, she says she is optimistic that the GED will get good marks in terms of cost and admission data. "We have some early preliminary data demonstrating that our interventions are in fact reducing patients' risks of admission," says Hwang, who is also collaborating with Biese, several healthcare associations, and the John A. Hartford Foundation to teach geriatric emergency department boot camps to hospitals interested in developing a GED.
"We've had lots of success stories in being able to navigate the patient to transition into the home in cases where they would otherwise have been admitted," says Nassisi. "We also have been able at times to send patients directly from the emergency department to a subacute rehab or other care facility when we've determined that it's not safe for them to go back home." The Mount Sinai GED has been so successful around care transitions that the organization is looking to expand the model to include younger patients who are at-risk for hospitalization.
At UNC, Biese notes that readmissions are going down. "With support from UNC Health Care leadership, the UNC ED has an enhanced and innovative case management program that contributed, along with other hospitalwide programs, to the relative rate of readmissions for the hospital dropping by over 10% and the absolute rate dropping by more than 3%."
